Emergency rooms are a safety net. But they no longer feel safe

Opinion: As medical students who will soon be responsible for patient care in B.C.’s emergency departments, we are alarmed by unsafe conditions

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A lethal combination of overcrowding, understaffing and violence is leading to suffering in hospital emergency departments across British Columbia. Some people are worse affected than others, widening health disparities.

As medical students who will soon be responsible for patient care in these emergency departments, we are alarmed. That’s why we’re calling on the provincial government to act swiftly to address the unsafe conditions.

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There are several causes of this crisis. With population growth, B.C.’s emergency departments are caring for more people than ever before. As the population ages, the cost of living rises, and mental health disorders become increasingly prevalent, patients arriving in emergency departments also have more complex needs than they have in the past.

Because of the shortage of primary care practitioners in B.C., many people do not have access to the preventive care that can keep them from ending up in acute health and mental health crises.

Once patients enter the health care system through the emergency departments, they are often left for long periods on stretchers, and even in hallways and chairs, until a hospital bed becomes available. This phenomenon, known as “access block,” is the result of inadequate capacity and inefficiency in the hospital system, along with a lack of alternatives to hospital care in the community.

The current conditions in B.C.’s emergency departments have considerable impacts on health.

Overcrowding is linked to violence against and burnout among health-care workers, as well as prolonged hospitalizations, more medical errors, and even patient deaths.

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These associations can be dramatic: One study from the United States showed that the risk of death doubled for patients waiting more than 12 hours for a hospital bed. In B.C., the median time that in-patients are kept in the emergency departments is 17.5 hours.

These impacts are not felt equally by all. People suffering health disparities — such as older people, people with mental health and substance use concerns, and people in rural, remote and Indigenous communities — are disproportionately exposed to these harms.

Older people tend to have more chronic health conditions than younger people. They are among the most frequent users of B.C.’s emergency departments. About one-quarter of all emergency department visits are by seniors. Many seniors live on low incomes and have unmet health-care needs.

In the crowded, chaotic environment of emergency departments, older people are at risk of developing life-threatening conditions like infections and delirium. Studies have demonstrated that, for an older individual, a night in an emergency department can increase the risk of death by up to 40 per cent.

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People experiencing poverty and with mental health and substance use disorders also frequently access emergency departments. They tend to be disconnected from longitudinal primary care as a result of social and structural barriers. In increasingly overcrowded emergency departments, these community members may be more at risk of discrimination and negative judgment, adding to their experiences of marginalization, and leading to departures against medical advice.

People living in rural areas — and particularly in rural Indigenous communities — experience poorer health and a lower life expectancy than their urban counterparts. First Nations, Métis, and Inuit communities, who face higher rates of chronic conditions and reduced access to primary care, are 75 per cent more likely to visit emergency departments than the general population. When rural emergency departments shut down for lack of staff, sometimes for weeks on end, these communities are deprived of access to emergency health care. Patients requiring a higher level of care can spend days in rural emergency departments waiting for transport, resulting in worse health outcomes.

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Despite this grim assessment, there are remedies to the crisis in B.C.’s emergency departments.

Increased capacity in primary care and more community-based supports are needed to prevent the progression of physical and mental health problems to the point of acute crisis.

These services also must be available when people are most likely to need them. Family doctors should be offered incentives to remain available to their patients by phone after hours.

The province must also invest in the infrastructure necessary to alleviate hospital access block. Even minor investments could make a big impact. Research has found that one to three per cent increases in hospital capacity could significantly reduce the time that sick patients are kept in emergency departments.

Better long-term care and supportive housing options for seniors and people with complex needs could help reduce unnecessary hospital stays, which, in addition to contributing to overcrowding, can be distressing and harmful to health.

Finally, investments and policies to reduce urban-rural disparities, particularly in access to higher levels of care, must be prioritized. Capacity for rural transport must be expanded and advanced care paramedics should be funded in strategic locations across rural B.C.

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Emergency departments are an essential safety net for people in B.C., and especially for the most vulnerable. But we have reached a point where emergency departments no longer feel safe for anyone. As future physicians, we are calling on the B.C. government to take urgent action on the unsafe conditions.

Only by addressing the crisis inside emergency departments do we have a hope of a healthier and more just society outside of them.

Sandra Smiley and Kathryn Haegedorn are third-year medical students and Christina Schwarz and Elaine Hu are second-year medical students at the University of British Columbia faculty of medicine.

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